January 15, 2020

Barbara Schneeman, PhD Chair, 2020 Dietary Guidelines Advisory Committee Dietary Guidelines Advisory Committee c/o USDA Food and Nutrition Service Center for Nutrition Policy and Promotion 3101 Park Center Drive, Room 1034; Alexandria, VA 22302

Re: Comments in response to Federal Register No. 2019-04543- Docket ID FNS-2019-0001, 2020 Dietary Guidelines Advisory Committee Proceedings Dear Dr. Schneeman and Members of the 2020 Dietary Guidelines Advisory Committee,

Drinking plain water in place of sugar-sweetened beverages (SSBs) is a simple, low-cost, feasible behavior modification that can have a major impact on intake of calories and added sugars by the U.S. population. We, the undersigned -- researchers, scientists, nutritionists, clinicians, public health professionals and public health advocates -- encourage the Dietary Guidelines Advisory Committee (DGAC) to provide strong recommendations in your report that urge USDA and HHS to state explicitly and unequivocally, in the new 2020 Dietary Guidelines for Americans, that water should be first for thirst and should be consumed in place of SSBs. Your recommendations should request the agencies to take the needed steps to add a symbol for water to the MyPlate graphic. Further, we recommend that your report provide clear, actionable information on ways to make plain water a beverage of choice, for example by recommending strategies to provide effective access to safe and appealing water, especially tap water, and to promote and educate about healthy beverages.1, 2, 3, 4, 5, 6, 7, 8 These recommendations will help reduce SSB consumption by supporting and enabling the healthy alternative, drinking water. (We wish to emphasize that we do not recommend discouraging dairy consumption or removing the dairy icon on MyPlate.)

Health impacts of sugar-sweetened beverages

Since a “Best of Science” letter was submitted to the previous DGAC in 2014 (attached), studies continue to confirm that SSBs are a leading contributor to the rates of obesity,9, 10, 11, 12, 13, 14 type 2 diabetes15, 16, 17, 18, 19 and other metabolic dysfunction (fatty liver disease, insulin resistance),20, 21, 22 heart disease (hypertension, dyslipidemia, stroke, coronary and cardiovascular disease)23, 24, 25, 26, 27, 28 and tooth decay.29, 30 Sources of liquid sugars, such as SSBs, may be uniquely harmful to health.31 Recent studies suggest SSB consumption may be linked to additional health impacts including increased risk of mortality,32 risk of asthma,33, 34 and the risk of certain cancers; further research is warranted.35

An ever more obese nation

Prevalence of overweight and obesity in the U.S. is at an all-time high.36, 37 A recent report predicts that our nation’s obesity crisis will continue to grow: that within just ten years (i.e., by 2030) nearly one-half of U.S. adults will have obesity; one-quarter will have severe obesity.38 Overweight is the primary disqualifier for fitness for U.S. military service.39 Type 2 diabetes and non-alcoholic fatty liver disease are afflicting more, and younger, people.40, 41, 42

SSBs remain heavily consumed

Graph courtesy of Kristine Madsen, MD, University of California, Berkeley

In recent years, public health efforts to promote a reduction in the consumption of SSBs have intensified.43, 44, 45, 46 Despite some success by these efforts as reflected in recent declines, consumption of SSBs remains well above recommended levels.47

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USDA ERS data

Trends in carbonated soft drink consumption in gallons per person per year

In order to support policy, practices and programs promoting water consumption and clear and consistent nutrition education on healthy beverage habits, as well as to message the public, we urge that both the Dietary Guidelines for Americans and MyPlate should clearly and consistently encourage the benefits of water consumption in place of SSBs.

Thank you for this opportunity to provide our comments.

Yours sincerely,

Organizations

Individuals

Abbey Alkon, RN, PNP, MPH, PhD Department of Family Health Care Nursing School of Nursing University of California, San Francisco

Jennifer Woo Baidal, MD, MPH Division of Pediatric Gastroenterology, Hepatology, and Nutrition Columbia University Medical Center New York-Presbyterian Morgan Stanley Children’s Hospital

GLOBAL TAP ™

Sara N. Bleich, PhD Harvard T.H. Chan School of Public Health Radcliffe Institute for Advanced Study Harvard Kennedy School Claire Brindis, DrPH Philip R. Lee Institute for Health Policy Studies Department of Pediatrics Department of Obstetrics, Gynecology, and Reproductive Health Sciences University of California, San Francisco Kelly D. Brownell, PhD World Food Policy Center Duke University David A. Cleveland, MS, PhD Environmental Studies Program and Department of Geography University of California, Santa Barbara Angie L. Cradock, ScD, MPE Harvard T.H. Chan School of Public Health Pat Crawford, DrPH, RD Nutrition Policy Institute Division of Agriculture & Natural Resources University of California William Dietz, MD, PhD Redstone Global Center for Prevention and Wellness Milken Institute School of Public Health The George Washington University Fatinah Darwish, MPH, RD Los Angeles County Department of Public Health Molly DeVinney, MPH Sugar Freedom Project Lori Dorfman, DrPH Berkeley Media Studies Group Jen Falbe, ScD, MPH, Nutrition and Human Development University of California, Davis

Jake Ferreira Mission: Readiness Tracy Fox, MPH, RD Food, Nutrition & Policy Consultants, LLC Anne Froment Division of Nephrology and Hypertension University of North Carolina at Chapel Hill Christopher Gardner, PhD Stanford University Edward Giovannucci, MD, ScD Departments of Nutrition and Epidemiology Harvard T.H. Chan School of Public Health Praveen S. Goday, MBBS, CNSC Pediatric Gastroenterology and Nutrition Medical College of Wisconsin Anna Grummon, PhD, MSPH Harvard T.H. Chan School of Public Health Sarah Hampl, MD General Pediatrics and Weight Management Center for Children’s Healthy Lifestyles & Nutrition Children’s Mercy Kansas City University of Missouri, Kansas City School of Medicine Jeannie Huang, MD, MPH Pediatric Gastroenterology Hepatology and Nutrition University of California San Diego Rady Children’s Hospital San Diego Glenda Humiston Vice President, Agriculture and Natural Resources University of California, Office of the President David L. Katz, MD, MPH True Health Initiative Yale-Griffin Prevention Research Center

Cristin Kearns, DDS, MBA Philip R. Lee Institute for Health Policy Studies Division of Oral Epidemiology & Dental Public Health School of Dentistry University of California, San Francisco Hannah Lawman, PhD Drexel University Ingrid Lofgren, PhD, MPH, RD Department of Nutrition and Food Sciences College of Health Sciences University of Rhode Island Robert H. Lustig, MD Division of Endocrinology Weight Assessment for Teen and Child Health (WATCH) Program University of California, San Francisco Kristine Madsen, MD, MPH Berkeley Food Institute School of Public Health University of California, Berkeley Vasanti Malik, ScD Department of Nutritional Sciences, Faculty of Medicine University of Toronto Department of Nutrition Harvard T.H. Chan School of Public Health Tania Marquez, MPH Los Angeles County Department of Public Health Ashley E. Mason, PhD Department of Psychiatry Osher Center for Integrative Medicine University of California, San Francisco Kathleen J. Melanson, PhD, RD, LDN Department of Nutrition and Food Sciences College of Health Sciences University of Rhode Island Shu Wen Ng, PhD, FTOS Department of Nutrition Gillings School of Global Public Health University of North Carolina at Chapel Hill

Brietta M. Oaks, PhD, MPH Department of Nutrition and Food Sciences College of Health Sciences University of Rhode Island Anisha Patel, MD, MSPH, MSHS Stanford University Rafael Pérez-Escamilla, PhD, Dr. Honoris Causa Member of the National Academy of Medicine Yale School of Public Health Gregory Pierce, PhD Luskin Center for Innovation University of California, Los Angeles Barry M. Popkin, PhD Department of Nutrition University of North Carolina at Chapel Hill Francisco Ramos-Gomez, DDS, MS, MPH Section of Pediatric Dentistry School of Dentistry University of California, Los Angeles Eric Rimm, ScD Harvard T.H. Chan School of Public Health Daniel Rizik-Baer, MSW Los Angeles County Department of Public Health Mica Root Johns Hopkins Bloomberg School of Public Health Asher Yoel Rosinger, PhD, MPH Pennsylvania State University Marlene B. Schwartz, PhD Rudd Center for Food Policy & Obesity University of Connecticut

Laura Schmidt, PhD, MSW, MPH Philip R. Lee Institute for Health Policy Studies Department of Anthropology, History and Social Medicine School of Medicine University of California, San Francisco Dipa Shah, MPH, RD Los Angeles County Department of Public Health Carmen Byker Shanks, PhD, RDN College of Education, Health & Human Development Montana State University Sonya Shin, MD, MPH Harvard Medical School Brigham and Women's Hospital Wendelin Slusser, MD, MS, FAAP David Geffen School of Medicine Fielding School of Public Health University of California, Los Angeles Karen Sokal-Gutierrez, MD, MPH School of Public Health University of California, Berkeley Kimber L. Stanhope, PhD, MS, RD Department of Molecular Biosciences University of California, Davis Jodi Stookey, PhD Nutrition Epidemiology Arizona State University

Mary Story, PhD, RD Duke Global Health Institute, Duke University Healthy Eating Research National Program, Robert Wood Johnson Foundation Qi Sun, MD, ScD Harvard T.H. Chan School of Public Health Jezra Thompson Gardening and Cooking Program Berkeley Unified School District Alison Tovar, PhD, MPH Department of Nutrition and Food Sciences College of Health Sciences University of Rhode Island Lara Turnbull, MPH Southern California Public Health Association Maya Vadiveloo, PhD, RD Department of Nutrition and Food Sciences University of Rhode Island Petra Wilder-Smith DDS, PhD Beckman Laser Institute Chai Family Comprehensive Cancer Center University of California Irvine Stella Lucia Volpe, PhD, RDN, ACSM-CEP, FACSM Department of Nutrition Sciences College of Nursing and Health Professions Drexel University" Laura Zatz, MPH Harvard T.H. Chan School of Public Health

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